LEVAQUIN® (levofloxacin IV/tablets)

A 44-year-old man with a 2-month
history of weight loss, fatigue, cough,
and night sweats
Joe Kovaz, M.D.
December 8, 2004
No financial disclosures
44 yo man with the following problems:
– Ischemic Heart Disease (stenting of right coronary
artery 10/01)
– Ventricular Septal Defect and Atrial Septal Defect
– Tobacco Addiction (2 packs daily for many years)
– Type II Diabetes Mellitus
– Obstructive Sleep Apnea
– Hyperlipidemia
– Hypertension
– Chronic cellulitis/erysipelas of left leg
Discontinued all of his medications one week prior to
his visit because: “They were killing me.”
– Simvastatin 80 mg
– Niaspan 2000 mg
– Losartan/hydrochlorothiazide 100/25
– Aspirin 325 mg
– Atenolol 100 mg
– Spironolactone 25 mg twice a day
– Metformin 500 mg twice a day
– Flonase
Had multiple dental extractions done in early
June while taking dicloxacillin 1 gram twice a
day and benzathine penicillin 1.2 million units
every four weeks. Had been on this regimen
since 9/03.
Felt somewhat better after stopping his
medications, but still had a cough and night
Past Medical History
Chronic cellulitis/erysipelas began in 10/02 after he
was hit in the left leg with a sledge hammer by one
son and a week later with a brick by another son.
Admitted for incision and drainage of an abscess of
the left leg.
…had six additional episodes of cellulitis from 10/02
to 8/03 which responded to oral antibiotics, except
for one episode requiring admission.
Past Medical History, continued
First seen by Dr. Vogelman, who initiated
treatment with dicloxacillin for recurrent
cellulitis and terbinafine for tenia pedis.
Benzathine penicillin 1.2 million units
intramuscularly every four weeks was added
for strep coverage.
Past Medical History, continued
Last seen by Dr. Vogelman on 8/26/04 who
stopped antibiotics due to complete clearing
of cellulitis/erysipelas.
Noted anemia (Hct 33) as well as a 2 month
history of weight loss, fatigue, myalgias, and
night sweats.
Physical Exam
Pulse: 112 bpm
BP: 148/80 mmHg
Temperature: 99°F
Chest: Clear
Heart: Harsh IV/VI systolic murmur along
the left sternal margin, apex and base.
Well healed scar, left leg
Initial Lab and X-Rays
Sed Rate: 115
Normal PA and Lateral Chest Film/Sinus
Additional Lab and Imaging Studies
Initial blood culture grew Strep viridans (within 18
hours) followed by two subsequent sets which also
grew Strep viridans (6 of 6 bottles)
Transthoracic echocardiogram—no vegetations. VSD
and ASD noted.
Transesophageal echocardiogram—sub-pulmonic
pedunculated mass in the RV outflow tract. Located
where flow across the VSD hits the outflow track.
Pulmonic regurgitation.
Hospital Course
Admitted and started on intravenous penicillin.
Gentamycin was added later.
Infectious disease consult—Strep viridans probably
due to dental work.
MIC Ceftriaxone .064 s Penicillin .064-.125 s
Discharged on Ceftriaxone 2 grams IV daily.
“I never knew I could feel this good.”
Learning Objectives
Recognize the protean signs and symptoms
associated with bacterial endocarditis
Become familiar with the common microorganisms
which cause acute and subacute bacterial
Become familiar with the Modified Duke Criteria for
the diagnosis of infective endocarditis
Review the current recommendations for the
treatment of, and prophylaxis for infective
 Microbial infection of a cardiac valve or mural
Almost 100% in preantibiotic era
10% streptococcal endocarditis
35% staphylococcal endocarditis
25-50% with prosthetic valve endocarditis
20,000-30,000 new cases/year primarily
among newborn and elderly
Causes of Prosthetic Valve Endocarditis
Blood is driven from a high pressure area
through a cardiac defect into a low pressure
A platelet-fibrin aggregate forms in the low
pressure sink.
During bacteremia, avirulent/virulent
organisms adhere to the platelet-fibrin
aggregate forming a vegetation.
Clinical presentations
Subacute bacterial endocarditis
– Duration of more than six weeks
Symptoms may begin insidiously and last for
Fever, sweats, weakness, myalgias,
arthralgias, malaise, anorexia, and
fatigability are common
Subacute bacterial endocarditis, continued
May be caused by avirulent bacteria, such as
streptococci which are part of the indigenous
Cutaneous manifestations
– Petechiae-conjunctivae, oropharynx, skin
– Osler’s nodes—tender, purplish subcutaneous nodules
in the pulp of the fingers
– Janeway lesions-nodular, nonpainful erythematous or
hemorrhagic areas on the palms or soles.
Subacute bacterial endocarditis, continued
Musculoskeletal features—myalgias,
arthralgias, arthritis
Ocular findings—Roth spots—oval
white areas surrounded by a zone of
Splenomegaly—15-30% with infarcts in 40%
and abscesses in 5% of patients with SBE
Subacute bacterial endocarditis, continued
Renal manifestations
– Hematuria in 50%
– Embolic renal infarction—flank pain
– Membranoproliferative glomerulonephritis
Embolic phenomenon (cerebral or systemic)
Mycotic aneurysms
Subacute bacterial endocarditis, continued
Neurological complications
30-40% due
either to emboli or mycotic aneurysms
Cardiac findings
– Murmur present in 90% of patients
– Heart failure-usually due to involvement of
aortic or mitral valves
– New conduction abnormalities due to
involvement of the membranous septum in the
area of the AV node
Acute bacterial endocarditis
Organisms are more invasive (s. aureus,
s pneumoniae, gram negative bacilli)
Onset is abrupt, with rigors and temperatures
over 102° F (duration less than six weeks)
Cutaneous manifestations, petechiae may be
prominent, especially when caused by
s. aureus
Emboli are common
Metastatic infections-cause organ-specific
 60% of vegetations can be detected using
transthoracic echocardiography
87-94% of vegetations can be detected with
transesophageal echocardiography
Transesophageal echocardiography is
indicated as the initial method for difficult to
image patients, possible prosthetic valve
infections, in patients with intermediate to
high clinical suspicion or in patients for a high
risk of complications